Point-of-care CD4 testing to inform selection of antiretroviral medications in South African antenatal clinics

A cost-effectiveness analysis

Andrea L. Ciaranello, Landon Myer, Kathleen Kelly, Sarah Christensen, Kristen Daskilewicz, Katie Doherty, Linda Gail Bekker, Taige Hou, Robin Wood, Jordan A. Francke, Kara Wools-Kaloustian, Kenneth A. Freedberg, Rochelle P. Walensky

Research output: Contribution to journalArticle

8 Citations (Scopus)

Abstract

Background Many prevention of mother-to-child HIV transmission (PMTCT) programs currently prioritize antiretroviral therapy (ART) for women with advanced HIV. Point-of-care (POC) CD4 assays may expedite the selection of three-drug ART instead of zidovudine, but are costlier than traditional laboratory assays. Methods We used validated models of HIV infection to simulate pregnant, HIV-infected women (mean age 26 years, gestational age 26 weeks) in a general antenatal clinic in South Africa, and their infants. We examined two strategies for CD4 testing after HIV diagnosis: laboratory (test rate: 96%, result-return rate: 87%, cost: $14) and POC (test rate: 99%, result-return rate: 95%, cost: $26). We modeled South African PMTCT guidelines during the study period (WHO "Option A"): antenatal zidovudine (CD4 ≤350/μL) or ART (CD4>350/μL). Outcomes included MTCT risk at weaning (age 6 months), maternal and pediatric life expectancy (LE), maternal and pediatric lifetime healthcare costs (2013 USD), and cost-effectiveness ($/lifeyear saved). Results In the base case, laboratory led to projected MTCT risks of 5.7%, undiscounted pediatric LE of 53.2 years, and undiscounted PMTCT plus pediatric lifetime costs of $1,070/infant. POC led to lower modeled MTCT risk (5.3%), greater pediatric LE (53.4 years) and lower PMTCT plus pediatric lifetime costs ($1,040/infant). Maternal outcomes following laboratory were similar to POC (LE: 21.2 years; lifetime costs: $23,860/person). Compared to laboratory, POC improved clinical outcomes and reduced healthcare costs. Conclusions In antenatal clinics implementing Option A, the higher initial cost of a one-time POC CD4 assay will be offset by cost-savings from prevention of pediatric HIV infection.

Original languageEnglish (US)
Article number0117751
JournalPLoS One
Volume10
Issue number3
DOIs
StatePublished - Mar 1 2015

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Point-of-Care Systems
cost effectiveness
Cost effectiveness
Pediatrics
drug therapy
Cost-Benefit Analysis
Mothers
HIV
health care costs
Life Expectancy
Costs and Cost Analysis
HIV infections
Testing
therapeutics
Costs
assays
testing
Zidovudine
gestational age
Assays

ASJC Scopus subject areas

  • Agricultural and Biological Sciences(all)
  • Biochemistry, Genetics and Molecular Biology(all)
  • Medicine(all)

Cite this

Ciaranello, A. L., Myer, L., Kelly, K., Christensen, S., Daskilewicz, K., Doherty, K., ... Walensky, R. P. (2015). Point-of-care CD4 testing to inform selection of antiretroviral medications in South African antenatal clinics: A cost-effectiveness analysis. PLoS One, 10(3), [0117751]. https://doi.org/10.1371/journal.pone.0117751

Point-of-care CD4 testing to inform selection of antiretroviral medications in South African antenatal clinics : A cost-effectiveness analysis. / Ciaranello, Andrea L.; Myer, Landon; Kelly, Kathleen; Christensen, Sarah; Daskilewicz, Kristen; Doherty, Katie; Bekker, Linda Gail; Hou, Taige; Wood, Robin; Francke, Jordan A.; Wools-Kaloustian, Kara; Freedberg, Kenneth A.; Walensky, Rochelle P.

In: PLoS One, Vol. 10, No. 3, 0117751, 01.03.2015.

Research output: Contribution to journalArticle

Ciaranello, AL, Myer, L, Kelly, K, Christensen, S, Daskilewicz, K, Doherty, K, Bekker, LG, Hou, T, Wood, R, Francke, JA, Wools-Kaloustian, K, Freedberg, KA & Walensky, RP 2015, 'Point-of-care CD4 testing to inform selection of antiretroviral medications in South African antenatal clinics: A cost-effectiveness analysis', PLoS One, vol. 10, no. 3, 0117751. https://doi.org/10.1371/journal.pone.0117751
Ciaranello, Andrea L. ; Myer, Landon ; Kelly, Kathleen ; Christensen, Sarah ; Daskilewicz, Kristen ; Doherty, Katie ; Bekker, Linda Gail ; Hou, Taige ; Wood, Robin ; Francke, Jordan A. ; Wools-Kaloustian, Kara ; Freedberg, Kenneth A. ; Walensky, Rochelle P. / Point-of-care CD4 testing to inform selection of antiretroviral medications in South African antenatal clinics : A cost-effectiveness analysis. In: PLoS One. 2015 ; Vol. 10, No. 3.
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abstract = "Background Many prevention of mother-to-child HIV transmission (PMTCT) programs currently prioritize antiretroviral therapy (ART) for women with advanced HIV. Point-of-care (POC) CD4 assays may expedite the selection of three-drug ART instead of zidovudine, but are costlier than traditional laboratory assays. Methods We used validated models of HIV infection to simulate pregnant, HIV-infected women (mean age 26 years, gestational age 26 weeks) in a general antenatal clinic in South Africa, and their infants. We examined two strategies for CD4 testing after HIV diagnosis: laboratory (test rate: 96{\%}, result-return rate: 87{\%}, cost: $14) and POC (test rate: 99{\%}, result-return rate: 95{\%}, cost: $26). We modeled South African PMTCT guidelines during the study period (WHO {"}Option A{"}): antenatal zidovudine (CD4 ≤350/μL) or ART (CD4>350/μL). Outcomes included MTCT risk at weaning (age 6 months), maternal and pediatric life expectancy (LE), maternal and pediatric lifetime healthcare costs (2013 USD), and cost-effectiveness ($/lifeyear saved). Results In the base case, laboratory led to projected MTCT risks of 5.7{\%}, undiscounted pediatric LE of 53.2 years, and undiscounted PMTCT plus pediatric lifetime costs of $1,070/infant. POC led to lower modeled MTCT risk (5.3{\%}), greater pediatric LE (53.4 years) and lower PMTCT plus pediatric lifetime costs ($1,040/infant). Maternal outcomes following laboratory were similar to POC (LE: 21.2 years; lifetime costs: $23,860/person). Compared to laboratory, POC improved clinical outcomes and reduced healthcare costs. Conclusions In antenatal clinics implementing Option A, the higher initial cost of a one-time POC CD4 assay will be offset by cost-savings from prevention of pediatric HIV infection.",
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AU - Kelly, Kathleen

AU - Christensen, Sarah

AU - Daskilewicz, Kristen

AU - Doherty, Katie

AU - Bekker, Linda Gail

AU - Hou, Taige

AU - Wood, Robin

AU - Francke, Jordan A.

AU - Wools-Kaloustian, Kara

AU - Freedberg, Kenneth A.

AU - Walensky, Rochelle P.

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N2 - Background Many prevention of mother-to-child HIV transmission (PMTCT) programs currently prioritize antiretroviral therapy (ART) for women with advanced HIV. Point-of-care (POC) CD4 assays may expedite the selection of three-drug ART instead of zidovudine, but are costlier than traditional laboratory assays. Methods We used validated models of HIV infection to simulate pregnant, HIV-infected women (mean age 26 years, gestational age 26 weeks) in a general antenatal clinic in South Africa, and their infants. We examined two strategies for CD4 testing after HIV diagnosis: laboratory (test rate: 96%, result-return rate: 87%, cost: $14) and POC (test rate: 99%, result-return rate: 95%, cost: $26). We modeled South African PMTCT guidelines during the study period (WHO "Option A"): antenatal zidovudine (CD4 ≤350/μL) or ART (CD4>350/μL). Outcomes included MTCT risk at weaning (age 6 months), maternal and pediatric life expectancy (LE), maternal and pediatric lifetime healthcare costs (2013 USD), and cost-effectiveness ($/lifeyear saved). Results In the base case, laboratory led to projected MTCT risks of 5.7%, undiscounted pediatric LE of 53.2 years, and undiscounted PMTCT plus pediatric lifetime costs of $1,070/infant. POC led to lower modeled MTCT risk (5.3%), greater pediatric LE (53.4 years) and lower PMTCT plus pediatric lifetime costs ($1,040/infant). Maternal outcomes following laboratory were similar to POC (LE: 21.2 years; lifetime costs: $23,860/person). Compared to laboratory, POC improved clinical outcomes and reduced healthcare costs. Conclusions In antenatal clinics implementing Option A, the higher initial cost of a one-time POC CD4 assay will be offset by cost-savings from prevention of pediatric HIV infection.

AB - Background Many prevention of mother-to-child HIV transmission (PMTCT) programs currently prioritize antiretroviral therapy (ART) for women with advanced HIV. Point-of-care (POC) CD4 assays may expedite the selection of three-drug ART instead of zidovudine, but are costlier than traditional laboratory assays. Methods We used validated models of HIV infection to simulate pregnant, HIV-infected women (mean age 26 years, gestational age 26 weeks) in a general antenatal clinic in South Africa, and their infants. We examined two strategies for CD4 testing after HIV diagnosis: laboratory (test rate: 96%, result-return rate: 87%, cost: $14) and POC (test rate: 99%, result-return rate: 95%, cost: $26). We modeled South African PMTCT guidelines during the study period (WHO "Option A"): antenatal zidovudine (CD4 ≤350/μL) or ART (CD4>350/μL). Outcomes included MTCT risk at weaning (age 6 months), maternal and pediatric life expectancy (LE), maternal and pediatric lifetime healthcare costs (2013 USD), and cost-effectiveness ($/lifeyear saved). Results In the base case, laboratory led to projected MTCT risks of 5.7%, undiscounted pediatric LE of 53.2 years, and undiscounted PMTCT plus pediatric lifetime costs of $1,070/infant. POC led to lower modeled MTCT risk (5.3%), greater pediatric LE (53.4 years) and lower PMTCT plus pediatric lifetime costs ($1,040/infant). Maternal outcomes following laboratory were similar to POC (LE: 21.2 years; lifetime costs: $23,860/person). Compared to laboratory, POC improved clinical outcomes and reduced healthcare costs. Conclusions In antenatal clinics implementing Option A, the higher initial cost of a one-time POC CD4 assay will be offset by cost-savings from prevention of pediatric HIV infection.

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